Understand Sub Limits in Your Health Insurance

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Written by PolicyBazaar

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Updated date : 16 November 2016

Buying a health insurance may be easy but selecting a plan that meets your needs is not that easy. There are various features such as day care procedures, waiting period, co-payment, deductibles and cashless cover that form the basis on which you can compare health insurance plans. However, one of the major key deciding factors is the sub-limit.

A sub-limit is an extra limit in an insurance policy’s coverage of certain losses. These losses are a part of the original policy limit, that is, the sum assured. Your insurance company can limit its liability in specific cases by including sub-limits. If you have a health insurance plan without sub-limits then it may cost you more, whereas, the plans with sub-limits are comparatively cheaper.

In simpler terms, a sub-limit is a monetary cap that your insurance service provider places on your medical insurance claim. Sub-limits can be placed on hospital room rent, doctor’s consultation fee, ambulance charges and a few pre-planned medical procedures such as cataract removal, knee ligament reconstruction, etc.

Importance of a sub-limit in a health insurance policy

A sub-limit is one of the critical features to evaluate in health insurance. They are usually expressed as a fixed value for a particular illness/disease or treatment but can also be included as percentage of the total sum insured. Many health insurance providers place two kinds of sub-limits on the insured – on the hospital room rent and the sum assured for specific diseases. Some companies also provide the insured the option to opt for or opt out of sub-limits. Depending on your budget, you can opt for either of the two but remember that an insurance plan with no sub-limits has a higher premium. Also, check if charges such as room rent and medical costs are within the reimbursable limit before getting treated in any hospital.

Let’s understand the two key sub-limits so that policy buying is better and easier for you:

1. Sub-limit on room rent

Under the room rent sub-limit option, your insurance company covers the room rent per day but only up to a certain limit. The type of the room is also capped. For instance, the insurer includes only the general room or semi-private room in its insurance plans. If you need a private room then you may have to pay extra for it from your pocket. If your room rent cap in your insurance plan is Rs 4000 per day and you opt for a room that costs Rs 6000 per day, you will have to pay the difference of Rs 2000 from your pocket

Also, hospital charges are linked with the type of room you opt for. Most of the medical expenses such as surgical procedures, doctor’s consultation charges or operation theatre fee may vary depending on the type of room you are staying in. A twin-sharing room or a general room may cost less as compared to a private room. However, it is advisable that you discuss this sub-limit clause with your insurance provider to avoid any last-minute confusion during your hospitalization or while filing a claim.

Before you decide to buy a policy with a sub limit on specific treatment, you must check the list of diseases/ailments which come under the sub limits clause and the costs specified against each of them. Even though your sum insured is high, but you may not be claiming your entire hospitalization expenses due to the sublimit clause on specific medical procedures. For instance, if there is a sub limit clause of 50% of sum assured for cancer treatment, then even if your total sum assured is Rs 10 lakh, you cannot claim more than Rs 5 lakh due to the sub limit clause.

Therefore, if you want to make sure that your hospitalization and claim procedure to be hassle-free , it is important that you go through the sub-limit clauses and choose only those policies, which does not contain certain discomfiting clauses and yet meet your budget and needs.

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